Nurse's Pocket Guide

• Ascertain knowledge of safety needs/injury prevention and
motivation to prevent injury in home, community, and work
setting.
• Note socioeconomic status/availability and use of resources.
• Assess influence of client’s lifestyle/stress on potential for injury.
• Review history of accidents noting circumstances (e.g., time
of day, activities coinciding with accident, who was present,
type of injury sustained).
• Determine potential for abusive behavior by family members/SO(s)/peers.
• Review diagnostic studies /laboratory tests for impairments/
imbalances that may result in/exacerbate conditions, such as
confusion, tetany, pathological fractures, etc.
NURSING PRIORITY NO.2.To promote safety measures required by
individual situation:
• Implement interventions regarding safety issues when planning
for client care and/or discharge from care. Failure to
accurately assess, intervene, and/or refer these issues can
place the client at needless risk and create negligence issues
for the healthcare practitioner:
Orient client to environment.
Make arrangement for call system for bedridden client in
home/hospital setting. Demonstrate use and place device
within client’s reach.
Keep bed in low position or place mattress on floor, as appropriate.
Use and pad side rails, as indicated.
Provide seizure precautions.
Lock wheels on bed/movable furniture. Clear travel paths.
Provide adequate area lighting.
Assist with activities and transfers, as needed.
Provide well-fitting, non-skid footwear.
Demonstrate/monitor use of assistive devices, such as cane,
walker, crutches, wheelchair, safety bars.
Provide supervision while client is smoking.
Provide for appropriate disposal of potentially injurious
items (e.g., needles, scalpel blades).
Follow facility protocol/closely monitor use of restraints,
when required (e.g., vest, limb, belt, mitten).
NURSING PRIORITY NO.3.To treat underlying medical/psychiatric
condition:
• Assist with treatments for underlying medical/surgical/psychiatric
conditions to improve cognition/thinking processes,
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 719
risk for TRAUMA